A Matter of Time: Does Gestational Age Affect the Duration of the Fetal Anatomic Survey?

OBJECTIVE: To assess the average duration of detailed fetal anatomic surveys in pregnancy in relation to gestational age (GA) and the maternal body mass index (BMI) to determine optimal timing of the examination. METHODS: This was a retrospective cohort study of gravidae presenting for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding examinations expected to have longer duration (ie, multifetal, major fetal anomalies), there were a total of 6522 examinations performed between GAs of 18 weeks 0 days and 22 weeks 0 days. Women were grouped by BMI, and results were analyzed by logistic regression. RESULTS: Gravidae of normal weight (BMI, 18.5-24.9 kg/m2 ) had a decrease of 47.47 seconds of the examination time with each increasing week of gestation (P = .036). Overweight (BMI, 25-29.9 kg/m2 ) gravidae similarly had a decrease of 66.31 seconds of the examination time with each additional week of gestation (P = .017). Underweight (BMI, 8.5 kg/m2 ) and obese (BMI, ≥30 kg/m2 ) gravidae did not have differences in the examination time with increasing GA. Increases in suboptimal examinations were noted with an increasing BMI (P < .001). There was a decreased frequency of suboptimal examinations in obese gravidae with a BMI of 40 kg/m2 or higher with increasing GA (P = .037). CONCLUSIONS: The duration of detailed fetal anatomic examinations decreased with increasing GA in normal-weight and overweight gravidae but not in obese gravidae. Performing the anatomy scan earlier in class I and II obese gravidae (BMI, 30-40 kg/m2 ) may enable improved pregnancy management options without increasing the examination duration or likelihood of a suboptimal evaluation.

Metformin Exposure and Risk of Hypertensive Disorders of Pregnancy in Patients with Type 2 Diabetes.

OBJECTIVE: Metformin has been found to have a role in promoting vascular remodeling and angiogenesis which may reduce the risk of developing preeclampsia. Prior studies have shown a decrease in the incidence of hypertensive disorders of pregnancy in patients with type 2 and gestational diabetes taking metformin. We hypothesize metformin exposure decreases the risk of developing hypertension in patients with type 2 diabetes. STUDY DESIGN: Retrospective cohort study from 2009 to 2019 of singleton pregnancies was complicated by type 2 diabetes. We compared patients who received metformin throughout pregnancy to those with no metformin exposure. The primary outcome was a hypertension composite defined as gestational hypertension, preeclampsia with or without severe features, HELLP syndrome, or eclampsia. Individual hypertensive outcomes and neonatal outcomes were secondarily evaluated. Logistic regression was used to adjust for confounding variables. RESULTS: A total of 254 pregnancies were included. Women exposed to metformin were significantly less likely to develop hypertension composite compared with nonexposed women (22.7 vs. 33.1%, aOR 0.53, 95% CI 0.29-0.96). The incidence of preeclampsia with severe features was also significantly lower in those who received metformin compared with those who did not (12.1 vs. 20.7%, aOR 0.38, 95% CI 0.18-0.81). There were no differences in preterm birth prior to 34 or 37 weeks, fetal growth restriction, or birth weight between the study groups. A subgroup analysis of women without chronic hypertension also had a significantly lower risk of developing preeclampsia with severe features (7.6 vs. 17.8%, aOR 0.35, 95% CI 0.13-0.94). CONCLUSION: Metformin exposure was associated with a decreased risk of composite hypertensive disorders of pregnancy in patients with pregestational type 2 diabetes. These data suggest that there may be benefit to metformin administration beyond glycemic control in this patient population. KEY POINTS: · Metformin use showed a decreased risk of a hypertension composite.. · Results were consistent in patients without chronic hypertension.. · Metformin may show benefit beyond glycemic control in women with type 2 diabetes..

Implementation and Outcomes of Universal Delayed Umbilical Cord Clamping at Term.

OBJECTIVE: To evaluate the implementation of an institutional protocol for universal delayed umbilical cord clamping (DCC) at term on maternal, neonatal, and umbilical cord blood gas outcomes. STUDY DESIGN: This is a retrospective cohort study of singleton term gestations from April through July 2017. On June 1, 2017, a protocol was implemented for DCC in all deliveries. Outcomes were compared between patients delivered prior to and those delivered after implementation. The primary outcome was postpartum hemorrhage (PPH). Secondary outcomes were additional adverse maternal, neonatal, and umbilical cord blood gas outcomes. Multivariable logistic regression was used to adjust for potential confounders. RESULTS: Of 682 patients, 341 were delivered preprotocol and 341 were delivered postprotocol. After implementation, there was 91.8% adherence to the protocol. Overall, there was no significant difference in PPH between patients delivered preprotocol and those delivered postprotocol (8.2 vs. 13.2%; adjusted relative risk [aRR]: 1.26, 95% confidence interval [CI]: 0.98-1.51). There was a significant decrease in the ability to obtain paired arterial and venous umbilical cord blood gases from preprotocol to postprotocol (83 vs. 63.6%; aRR: 0.62 [95% CI: 0.50-0.76]). There were no significant differences in abnormal umbilical cord blood gases or neonatal outcomes. CONCLUSION: We did not find an increased risk of adverse outcomes associated with the widespread use of DCC.

Effect of Oligohydramnios on Fetal Heart Rate Patterns during Term Labor Induction.

OBJECTIVE: To estimate the effect of oligohydramnios on fetal heart rate (FHR) patterns in patients undergoing induction of labor (IOL) at term. STUDY DESIGN: Secondary analysis of a prospective cohort study of consecutive term, singleton deliveries from 2010 to 2015. We included all patients who underwent IOL. Our primary outcomes were electronic fetal monitoring (EFM) characteristics in the 2 hours preceding delivery. Outcomes were compared between those induced with oligohydramnios and those induced without a diagnosis of oligohydramnios. Our secondary outcome was composite neonatal morbidity. Logistic regression was used to control for confounders. RESULTS: Of 3,787 patients who underwent IOL, 147 had a diagnosis of oligohydramnios and 3,640 were included in the no oligohydramnios group. There was no significant difference in EFM characteristics between the two groups. There was no difference in composite neonatal morbidity. In patients with oligohydramnios, EFM patterns with baseline tachycardia for 30 minutes or greater were significantly associated with composite neonatal morbidity (31.3 vs. 5.3% adjusted odds ratio 8.63, 95% confidence interval 2.18, 34.1]). CONCLUSION: Term patients undergoing IOL with oligohydramnios had EFM patterns that did not differ from their induced peers.

Normal Cervical Effacement in Term Labor.

OBJECTIVE: To estimate the natural history of cervical effacement in labor. STUDY DESIGN: This is a retrospective cohort study of term, vertex, singletons who reached 10 cm of cervical dilation from 2010 to 2014. Interval-censored regression was used to estimate the median number of hours between changes in effacement (measured in centimeters of the residual cervix) and to estimate the median effacement at a given cervical dilation. Analysis was stratified by parity and labor type. RESULTS: In total, 7,319 patients were included. Multiparas had faster effacement from 1 cm to complete effacement than nulliparas, but nulliparas were significantly more effaced at each cervical dilation. Patients in spontaneous labor had faster effacement and were significantly more effaced at each centimeter of cervical dilation than those who were induced or augmented. Once active labor was established (>6 cm of cervical dilation), 95% of patients had an effacement of 1 cm or less. By 8 cm of cervical dilation, 50% of all patients were completely effaced. CONCLUSION: There is a wide range in the normal length of time for the progression of cervical effacement. However, once a patient is in active labor, 95% of patients have effaced to 1 cm or less.

Delivery Outcomes after Term Induction of Labor in Small-for-Gestational Age Fetuses.

Objective The objective of this study was to estimate the delivery outcomes after induction of labor (IOL) at term in patients with small-for-gestational age (SGA) fetuses. Study Design A secondary analysis of a prospective cohort study of all term, singleton deliveries from 2010 to 2014. Patients who underwent an IOL for any indication were included. Delivery outcomes were compared between patients with and without SGA fetuses (defined as birth weight < 10th percentile for gestational age). Analysis was stratified by parity. Indication for cesarean was compared between the two groups for those who did not achieve vaginal delivery. Logistic regression was used to adjust for confounders. Results Of 3,787 patients who underwent an IOL, 644 patients had SGA fetuses and 3,143 were included in the non-SGA group. There was no significant difference in rate of successful vaginal delivery for patients with and without SGA fetuses (77.2 vs. 72.0% [adjusted odds ratio: 1.22, 95% confidence interval 1.00-1.50]). Of the patients who were delivered by cesarean, women with SGA fetuses were more likely to undergo cesarean for nonreassuring fetal status and less likely for arrest disorders than women without an SGA fetus. Conclusion Term patients undergoing IOL with SGA fetuses are as likely to achieve a vaginal delivery as patients with non-SGA fetuses.

Can Transabdominal Cervical Length Measurement Exclude Short Cervix?

OBJECTIVE: This study aims to determine if transabdominal (TA) cervical length may be used to rule out a short cervix on transvaginal (TV) ultrasound. STUDY DESIGN: We conducted a prospective cohort study of women undergoing routine anatomic survey at 17 to 23 weeks gestation. TA and TV cervical length measurements were obtained in each patient. A short cervix was defined as TV cervical length < 30 mm. Predictive characteristics were calculated for different cutoff values of TA cervical length. RESULTS: There were 404 patients enrolled, a TA cervical length could not be obtained in 83 women (20.6%) and 318 women had both TA and TV measurements. Of those, 14 (4.4%) had a TV cervical length < 30 mm. TA cervical length measurement ≥ 35 mm excluded the possibility of TV cervical length < 30 mm (negative predictive value, 99.5%; 95% confidence interval [CI], 97.4; 100%). In our cohort, 67.6% (95% CI, 62.2; 72.7%) of TV ultrasounds could have been avoided using a TA cervical length cutoff of ≥ 5 mm. CONCLUSION: ATA cervical length of at least 35 mm excludes a short cervix of < 30 mm. While TA cervical length screening may not be feasible in 1 in 5 women, it may be used to decrease the burden of universal TV cervical length screening.

Maternal-fetal medicine fellowship program director perspective on virtual interviews following matriculation of the first virtual interview class.

BACKGROUND: The first class of virtually interviewed maternal-fetal medicine fellows has matriculated into their training programs. OBJECTIVE: This study aimed to evaluate the impact of virtual interviews on the outcomes of the National Resident Matching Program within our subspecialty. We assessed maternal-fetal medicine fellowship program directors' experience with their fellows who interviewed virtually as compared with experience with the previous year's fellows who interviewed in-person. In addition, we evaluated program directors' satisfaction with the virtual interview process and their preferred mode of interviewing for future cycles. STUDY DESIGN: A cross-sectional online survey was distributed through the Society for Maternal-Fetal Medicine to all maternal-fetal medicine fellowship program directors on October 26, 2021, approximately 4 months after the first virtually interviewed fellow matriculated into the training program. Program directors were asked to provide information about their National Resident Matching Program rank list between their final in-person and first virtual years. Program directors were asked to evaluate their experience with their fellow 4 months into the first year of fellowship compared with their expectations based on their virtual interview, and their experience at that same point in fellowship of their last fellow who interviewed in-person. For all questions, in programs with >1 fellow per year, program directors were asked to answer the questions for the fellow ranked highest on their National Resident Matching Program rank list for each year. Survey data were collected anonymously and stored securely. Descriptive statistics and bivariate analyses were performed to compare groups, all tests were 2-sided, and the significance level was set at P<.05. RESULTS: A total of 80 of 98 (81.6%) program directors responded. There was no difference in the position of the matched fellow on the program's National Resident Matching Program rank list between candidates interviewed in-person and candidates interviewed virtually. There was also no difference in the number of programs that took an internal or external candidate outside of the National Resident Matching Program match process or that did not fill their fellowship positions. Program directors reported no difference between fellows interviewed virtually and those interviewed in-person in meeting interview-based performance expectations with regard to clinical capabilities (P=.67), technical skills (P=.96), research potential or experience (P=.54), professionalism and ability to be a team player (P=.72), and compatibility with the division and fellowship program (P=.67). Program directors' overall experience with virtual interviews was favorable: 70 (95.8%) program directors reported that the virtual interview experience was better than expected, slightly better than expected, or as expected. In future years, most program directors favored ongoing exclusively virtual interviewing (n=41; 56.2%) or a hybrid of virtual and in-person interviews (n=27; 37.0%). Only 5 (6.9%) reported a desire to return to exclusively in-person interviewing. CONCLUSION: Maternal-fetal medicine fellowship program directors did not identify a difference in National Resident Matching Program results between fellows interviewed virtually and those interviewed in-person. Furthermore, there was no difference between these fellows in meeting interview-based expectations in the first year of the training program. Most program directors found the virtual interview process to be effective and support ongoing virtual interviews.

Effect of virtual interviewing on applicant approach to and perspective of the Maternal-Fetal Medicine Subspecialty Fellowship Match.

BACKGROUND: The 2020 application cycle for the Maternal-Fetal Medicine Specialty Fellowship Match was the first to be exclusively virtual. OBJECTIVE: Our study was designed to compare approaches and perspectives of the MFM fellowship candidates who applied with virtual interviews with those of the current Maternal-Fetal Medicine fellows, who applied with in-person interviews in 2017, 2018, or 2019. STUDY DESIGN: A survey was developed by the Society for Maternal-Fetal Medicine Fellowship Affairs Committee to ascertain applicant approaches to and perspectives of the Maternal-Fetal Medicine Fellowship Match and was disseminated after 2020 Maternal-Fetal Medicine interviews ended and completed before Fellowship Match Day. Participants were contacted by means of active Listservs maintained by the Society for Maternal-Fetal Medicine. Current fellows were instructed to complete the survey using their experiences on the application cycle in which they successfully matched. Those who elected to participate entered their survey responses through the electronic link; answers were recorded in a secure Research Electronic Data Capture database. Outcomes were compared between those who applied during the virtual 2020 Maternal-Fetal Medicine interview cycle and those that applied during the in-person interview cycles in 2017, 2018, or 2019. RESULTS: Of the 140 completed surveys, 46 people participated in the 2020 Maternal-Fetal Medicine Match and were categorized as "virtual applicants," whereas the remaining 94 people participated in the 2017 (n=28), 2018 (n=33), or 2019 (n=33) Maternal-Fetal Medicine Match and were categorized as "in-person applicants." The overall distribution of number of programs to which each applicant applied differed between groups (P=.02); for example, nearly 75% of virtual applicants applied to at least 25 fellowship programs, compared with less than 50% of in-person applicants. Although the number of interviews received was similar between virtual and in-person applicants, virtual applicants were significantly less likely to cancel scheduled interviews (n=18 [39.1%] vs n=68 [72.3%]; P<.001). There were also differences between virtual and in-person applicants in terms of overall cost of the fellowship intervention process and total days away from work for interviewing (P<.001 for both). In particular, nearly two-thirds of virtual applicants reported spending less than $1000 in the Maternal-Fetal Medicine fellowship application process, compared with the nearly two-thirds of in-person applicants who reported spending more than $5000. Among the 46 virtual applicants, nearly 80% reported the experience was better or slightly better than expected, and none reported the experience was slightly worse or worse than expected. Nearly two-thirds of the virtual applicants reported that, compared with their in-person residency interviews, they received a comparable representation of Maternal-Fetal Medicine fellowship programs and could effectively assess their "fit" during interviews (60.9% and 63.0%, respectively). Only 20% of virtual Maternal-Fetal Medicine applicants would recommend returning to exclusive in-person interviews should that be possible in future Maternal-Fetal Medicine matches. CONCLUSION: Virtual Maternal-Fetal Medicine fellowship interviewing was viewed favorably by applicants but corresponded with significant changes to their application approaches. The differences between virtual and in-person fellowship applicant tendencies identified in this study should inform next year's application cycle for Maternal-Fetal Medicine and possibly other obstetrics and gynecology subspecialty fellowships.

Maternal-fetal medicine program director experience of exclusive virtual interviewing during the coronavirus disease 2019 pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic necessitated an abrupt transition to exclusive virtual interviewing for maternal-fetal medicine fellowship programs. OBJECTIVE: This study aimed to assess the maternal-fetal medicine fellowship program directors' approaches to exclusive virtual interviews and to obtain program director feedback on the virtual interview experience to guide future interview cycles. STUDY DESIGN: A novel cross-sectional online survey was distributed through the Society for Maternal-Fetal Medicine to program directors after the completion of the interview season, but before the results of the National Resident Matching Program on October 14, 2020. Survey data were collected anonymously and managed using secure Research Electronic Data Capture electronic data capture tools. RESULTS: Overall 71 of 89 program directors (80%) responded. All respondents completed their 2020 interviews 100% virtually. Nearly half of program directors (33 of 68, 49%) interviewed more candidates in 2020 than in 2019. Of those who interviewed more candidates in 2020, the mean number of additional candidates per fellowship position was 5.8 (standard deviation, ±3.8). Almost all program directors reported no (35 of 71, 49%) or minimal (34 of 71, 48%) negative impact of technical difficulties on their virtual interview processes. Most programs structured their interview to a half day (4 hours) or less for the candidates. Many programs were able to adapt their supplemental interview materials and events for the candidates into a virtual format, including a virtual social event hosted by 31 of 71 programs (44%). The virtual social event was most commonly casual and led by current fellows. Ultimately, all program directors reported that the virtual interview experience was as expected or better than expected. However, most program directors felt less able to provide candidates with a comprehensive and accurate representation of their program on a virtual platform compared with their previous in-person experiences (46 of 71 [65%] reported minimally, moderately, or significantly less than in-person). In addition, most program directors felt their ability to get to know candidates and assess their "fit" with the program was less than previous in-person years (44 of 71 [62%] reported minimally, moderately, or significantly less than in-person). In a hypothetical future year without any public health concerns, there were 23 of 71 respondents (32%) who prefer exclusive in-person interviews, 24 of 71 (34%) who prefer exclusive virtual interviews, and 24 of 71 (34%) who prefer a hybrid of virtual and in-person interviews. CONCLUSION: The virtual interview experience was better than expected for most program directors. However, most program directors felt less able to present their programs and assess the candidates on a virtual platform compared with previous in-person experiences. Despite this, most program directors are interested in at least a component of virtual interviewing in future years. Future efforts are needed to refine the virtual interview process to optimize the experience for program directors and candidates.

Prostaglandins and cesarean delivery for nonreassuring fetal status in patients delivering small-for-gestational age neonates at term.

Objective: Growth-restricted fetuses have been excluded from many randomized trials of prostaglandins for labor induction. As prostaglandins, particularly misoprostol, are associated with increased rates of cesarean delivery for nonreassuring fetal heart tracing, it is important to assess their safety in pregnancies at higher risk of this complication. The objective of this study was to estimate the association between use of prostaglandins for labor induction in term singleton pregnancies complicated by delivery of small-for-gestational age (SGA) neonates and the risk of cesarean delivery for nonreassuring fetal status (NRFS).Materials and methods: Retrospective cohort study of singleton deliveries ≥37 weeks following induction of labor in patients with SGA (birthweight <10% percentile for gestational age). Patients with prior cesarean delivery or neonates with major congenital anomalies were excluded. Patients were categorized by exposure to prostaglandins. The primary outcome was cesarean delivery for NRFS. Secondary outcomes were any cesarean delivery, a composite of a 5-min Apgar score <7, admission to the neonatal intensive care unit, or neonatal death, and a composite of maternal morbidity (transfusion, postpartum hemorrhage, wound infection, endometritis, fever). Propensity scores for exposure were estimated using a logistic regression model, including parity, comorbidities, and Bishop score. Stabilized weights from inverse probability of treatment weighting were used. Outcomes were compared with relative risks (RRs) and 95% confidence intervals (CIs).Results: There were 1097 patients: 587 (53.5%) exposed to prostaglandins and 510 (46.5%) unexposed. Covariates were balanced in the stabilized sample. Overall, 166 (15.1%) patients had cesarean deliveries for NRFS. In unadjusted analysis, prostaglandin use was associated with an increased RR of cesarean for NRFS (18.3 versus 11.0%, RR: 1.71, 95% CI: 1.27-2.30). In propensity-score-weighted analysis, the RR for cesarean for NRFS was 1.22 (95% CI: 0.93-1.59). There was no significant association between prostaglandin exposure and all-cause cesarean delivery, maternal morbidity, or neonatal morbidity.Conclusion: In propensity score analysis, there was no association between the use of prostaglandins for labor induction at term and cesarean for NRFS in pregnancies complicated by SGA. However, given the retrospective nature of the study, these results should be interpreted with caution.

Effect of a Home-Based Lifestyle Intervention on Breastfeeding Initiation Among Socioeconomically Disadvantaged African American Women with Overweight or Obesity.

BACKGROUND: Socioeconomically disadvantaged (SED) African American women with overweight or obesity are less likely to breastfeed. OBJECTIVE: To test whether a home-based lifestyle intervention impacts breastfeeding initiation rates in SED African American women with overweight or obesity. STUDY DESIGN: This was a secondary analysis of a randomized controlled trial from October 2012 to March 2016 at a university-based hospital within the LIFE-Moms consortium. SED African American women with overweight or obesity and singleton gestations were randomized by 16 weeks to Parents as Teachers (PAT)-a home-based parenting support and child development educational intervention-or PAT+, PAT with additional content on breastfeeding. Participants completed a breastfeeding survey. Outcomes included breastfeeding initiation and reasons for not initiating or not continuing breastfeeding. RESULTS: One hundred eighteen women were included: 59 in PAT+; 59 in PAT. Breastfeeding initiation rates were similar in each group (78.00% in PAT+; 74.58% in PAT). On a one to four scale, with four denoting "very important," women in PAT+ and PAT were equally likely to rate their beliefs that formula was better than breast milk or breastfeeding would be too inconvenient as the most important reasons to not initiate breastfeeding. On the same scale, women similarly rated their difficulty latching or concern for low milk supply as the most important reasons for breastfeeding cessation. CONCLUSION: SED African American women with overweight or obesity who received a home-based educational intervention had higher breastfeeding rates than is reported nationally for black women (59%). However, the intervention with more breastfeeding content did not further increase breastfeeding rates or impact reasons for breastfeeding cessation. TRIAL REGISTRATION: ClinicalTrials.gov : NCT01768793.

Defining and Managing Normal and Abnormal First Stage of Labor.

Modern data have redefined the normal first stage of labor. Key differences include that the latent phase of labor is much slower than was previously thought and the transition from latent to active labor does not occur until about 6 cm of cervical dilatation, regardless of parity or whether labor was spontaneous or induced. Providers should have a low threshold to use one of the safe and effective interventions to manage abnormal progression in the first stage of labor, including oxytocin, internal tocodynamometry, and amniotomy.